Laserfiche WebLink
—t <br /> W Ab <br /> 2otl <br /> San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL 4 &/ F 62, <br /> JOB ADDRESS: XCU W. CPERMIT SR# D v u <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of <br /> Division 3 of the California Business and Professions Code and my license is in full force and effect. <br /> License#: �7 �'` Exp Date: <br /> Date: / Contractor:_6&=�r.�/, <br /> Signature: Title: f �%�t <br /> Print Name: <br /> v1fORKERS' COMPENSA-1 iON DECLARATION <br /> 1 hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> I have and will maintain a certificate of consent to self-insure for workers' compensation, as <br /> provided for by Section 3700 of the Labor Code; for the performance of the work for which this <br /> permit is issued. <br /> I have and will maintain workers' compensation insurance, as required by Section 3700 of the <br /> Labor Cade, for the performance of the work for which this permit is issued. My workers' <br /> compensation insurance carrier and policy numbers are: <br /> Carrier- 6xR? � - Policy Number: <br /> I certify that in the performance of the work for which this permit is issued, 1 shall not employ any <br /> person in any manner so as to become subject to the workers' compensation law of California, <br /> and agree that if I should become subject to workers' compensation provisions of Section 3700 of <br /> the Labor Code, i shall forthwith comply with those provisions. <br /> Exp. Date:g C�✓l1 Signature: <br /> Print Name:`', <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$100,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AU H0R'TION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, v of C-57 licensed(signature ed authorized representative), <br /> hereby authorize(print name) S.�Q('aLi� l L `jK[,�'� to sign this San Joaquin County Well & Boring Permit <br /> Application on my behalf. I understand this authorization is valid for one year and is limited to the work <br /> plan dated on the front page of this application. <br /> EH❑29-01 07/20!10 WELL PERMIT APP <br />